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THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


,..,,,  \      X       V  ,<X  •        -       -X      \     \      \      \      \     \,V        • 


TREATMENT 


FRACTURE  OF  THE  JAW;" 

•j  j  i , 


AS   SENT   TO 


.    D.   F^AYBS   flGNBW,    CD. 


THOS.  BRIAN, GUNNING,,.D.  D.  S. 
i— — ^ 

NEW  YORK. 


BALTIMORE  : 
SNOWDEN  &  COWMAX.  PIUNTKIN, 

1884 

« 

| 

'  \\v\\ 


TREATMENT 


FRACTURE  OF  THE  JAW; 


AS    SKXT    TO 


D.   F)AYE3   flGNEW,    ffl.   D., 


THOS.  BRIAN^UNNING^.  D.  D.  S., 
NEW  YORK. 


BALTIMORE, 

SXOWDEN  A:  (  OWMAX.  PRIXTEKS, 
1884. 


Iff* 

TREATMENT  OF  FRACTURE  OF  THE  JAW 

WITH  CRITICAL   REMARKS. 


AS    -KNT    TO 


.  D.  F^AYES  pGNiiW,  (Q.  D 


The  four  splints  peculiar  to  my  treatment  illustrated  by 
cuts  and  also  by  selected  cases  in  which  they  had  been  used 
together  with  full  explanations  as  to  their  manufacture 
and  application  were  published  in  the  Xew  York  Medical 
Journal  for  September  and  October  1866  ;  The  British  Jour- 
nal of  Dental  Science  also  of  1866;  Dental  Cosmos,  Vol. 
VIII ;  AMERICAN  JOURNAL  OF  DENTAL  SCIENCE,  Third 
Series,  Vol.  2;  and  a  synopsis  is  given  in  "  Heath's  Injuries 
and  Diseases  of  the  Jaws."  Diagnosis  of  fracture  of  the  jaws 
was  not  however  dwelt  upon  ;  but  as  preparatory  to  this  in 
1867, 1  published  my  views  of  the  muscular  action  which  con- 
trols the  lower  jaw.  (See  New  York  Medical  Journal,  Vol. 
VI,  p.  193  ;  AMERICAN  JOURNAL  OF  DENTAL  SCIENCE.  Third 
Series,  Vol.  I,  p.  597  ;  Dental  Register,  Vol.  XXII,  p.  103. 

Early  in  1880  circumstances  made  it  necessary  that  the 
subject  should  be  again  taken  up  and  in  the  April  number 
of  the  Independent  Practitioner,  I  commenced  a  series  of 
articles  which  after  showing  the  action  of  the  muscles 
involved  and  speaking  at  length  upon  the  diagnosis  of  frac- 
tures of  the  lower  maxilla,  the  closing  paper  again  gave  a 
clear  view  of.  the  four  splints  used  in  my  treatment  of  these 
injuries. 

These  repeated  presentations  of  the  splints  have  however 
proved  insufficient  to  correct  the  misrepresentations  which 
have  appeared  to  confuse  and  mislead  the  reader ;  and  the 
three  years  which  have  just  closed,  show  a  condition  of 
affairs  which  calls  upon  me  to  take  decided  action  in  the 
matter  ;  I  therefore  again  bring  forward  the  splints  that  the 
reader  may  judge  as  to  my  strictures  on  those  who  have 
so  grossly  misrepresented  my  treatment. 


] XTRKDKNTAL   SPLINTS. 

In  the  year  1840,  when  treating  the  first  fractured  lower 
jaw  placed  in  my  care,  I  found  treatment  by  bandages 
unreliable,  For,  while  the  muscles  tend  to  displace  the 
bone,  bandages  frequently  increase  the  difficulty;  especially 
when  swelling  sets  in  through  their  pressure.  They  also, 
by  interfering  with  the  circulation,  tend  to  prevent  union. 
Teeth,  loosened  by  the  injury,  are  left  unsupported,  and  the 
motions  of  the  jaw,  cheeks  and  lips  painfully  restricted. 

Of  the  contrivances  invented  to  supplement  bandages, 
many  were  even  more  objectionable,  and  little  improvement 
has  been  made  in  general  treatment  up  to  the  present  time. 
Having  successfully  used  interdental  splints,  in  many  cases 
which  have  proved  unmanageable  under  the  usual  treat- 
ment, I  am  convinced  that  they  are  superior  to  all  other 
appliances. 

When  a  well  adapted  splint  is  on  the  teeth  and  gum  the 
other  parts  around  the  bone  are,  to  a  great  extent,  a  counter 
support  to  the  splint.  Thus  the  broken  jaw,  together  with 
any  teeth  loosened  by  the  injury,  is  held  securely  in  place, 
until  the  fractured  bone  is  re-united  and  the  teeth  become 
firm.  Meanwhile  the  motions  of  the  jaw  are  in  most  cases 
unrestricted  and  the  cheeks  and  lips  always  left  free. 

On  February  I2th,  1861,  I  applied  a  "vulcanized  hard 
rubber  splint"  to  the  fractured  jaw  of  a  seaman  in  the 
United  States  Naval  Hospital,  and  from  the  vulcanite  splints 
used  by  me  shortly  after,  I  selected  three  which  show  all  that 
is  essential  to  hold  any  fractured  lower  jaw  in  place. 

The  fourth,  a  metal  splint,  is  sufficient  for  the  treatment 
of  most  cases,  and  can  be  applied  by  surgeons  and  country 
practitioners,  who  can  also  treat  most  cases  of  fracture  with 
rubber  splints,  if  assisted  by  the  neighboring  dentist.* 


*The  splints  were  described  in  a  paper  read  before  the  New  York 
Academy  of  Medicine,  June  1st,  1864.  For  report  of  this,  and  the 
earlier  presentation  of  the  subject,  see  the  Academy  &  Bulletin,  Vol.  II, 
pp.  82,  83,  84,  85,  153,  168,  and  307,  also  "  Transactions  of  the  Medicul 
Society  of  the  State  of  New  York,  for  February  1863  :"  American  Medical 
Time*,  August  8th,  1863;  Dental  Cosmos,  September,  1863.  Haudbuch 


5 

The  radical  and  distinctive  feature  of  these  splints  is,  that, 
when  suitable  teeth  are  in ,  the  mouth,  nothing  is  required 
on  the  outside,  and  the  patient  may  move  about.  In  the 
use  of  these  splints  fractures  of  the  lower  jaw  are  divided 
into  two  distinct  classes ;  first,  those  in  which  the  teeth  and 
gum  of  the  fractured  jaw  are  alone  used  to  control  the  frac- 
tured bone,  and  the  jaw  is  allowed  to  move  naturally  ;  sec- 
ond, those  in  which  the  splint  is  fitted  to  both  the  upper  and 
lower  teeth,  the  jaw  being  held  still ;  but  no  bandage  is  used 
around  the  head. 

To  apply  these  splints  the  fractured  jaw7  should,  if  possi- 
ble, be  set  and  held  by  ligatures  around  the  teeth  while  an 
impression  of  the  teeth  and  gum  is  taken  in  pure  warm  wax 
confined  in  a  cup  like  No.  4  splint ;  the  plaster  cast  from 
the  impression  will  then  be  precisely  what  is  required  to 
mould  the  splint.  If  the  bone  cannot  be  held  in  place  an 
impression  may  be  taken  of  the  teeth  in  the  best  attainable 
position,  the  plaster  cast  then  separated  where  necessary  and 
the  parts  set  in  place ;  a  cast  of  the  upper  teeth  will  guide 
in  putting  these  parts  of  the  lowrer  cast  in  place. 

FIG.  I  represents  the  inner 
surface  of  a  splint  which  in- 
closes all  the  teeth  and  part  of  the 
gum  of  the  lo\ver  jaw,  and 
merely  rests  against  the  upper 
teeth  when  the  jaws  are  closed. 
This  splint  is  adapted  to  the 
treatment  of  all  cases  which  have 

The  holesKmarked    A    go  teeth  in  both  fragments, 
through  the  top  of  the  splint         The   angles    of    the  jaic   tend 
for  the  purpose  of  syringing  the  /         /  /        •  •      /- 

part   within  with   warm  water  outward,   Wften   tile  jaiv    is  frac- 
durmg  treatment.      The  dark  ture(f    through    the   front.       It   is 
round  spots  in  all  the  cuts  rep- 
resent holes  for  similar  purposes  therefore  necessary  that  the  splint 

should  go  down    and  extend  back  as  far  on  the  outside  as 


der  Lehre  Aron  Den   Knochenbruchen  von,  Dr.  E.  G-urlt,  Professor  der 
Chirurgie  an  der  Konighlichen  Universitat  zu  Berlin,  p.  438. 

All  these  works  give  verbatim  reports   from   the   proceedin       of  the 
Academy  of  Medicine,  January  7th,  1863. 


the  muscles  admit,  especially  on  the  short  fragment,  if 
there  is  much  difference  between  them.  The  parts  near 
the  external  oblique  line  are  so  formed  that  the  splint  can 
be  fitted  to  them  perfectly,  and  the  outer  ends  of  the 
splint,  should  be  quite  thick,  that  they  may  be  well  rounded. 

I  have  generally  used  this  splint  without  any  fastenings, 
but  in  children  and  even  adults  it  is  sometimes  advisable  to 
secure  it  by  pack-thread  or  wire,  or  by  screws  passing  into 
or  between  the  teeth,  or  by  the  wings  and  band  of  Fig.  4. 

When  screws  are  used  to  hold  any  rubber  splint  fast  on 
the  teeth,  metal  nuts  must  be  imbedded  in  the  splint,  for  the 
screws  to  work  in. 

Small  openings  should  be  made  opposite  particular  teeth, 
to  observe  how  the  jaw  stands  in  the  splint.  This  is  impor- 
tant in  all  splints. 

_~^^^. 

FIG.  2  shows  a  splint  for 
cases  in  which  it  is  found 
impracticable  to  hold  the  frag- 
ments together,  except  by 
keeping  the  fractured  bone 
still ;  this  splint,  in  addition  to 
fitting  the  teeth  and  gum  of  the 
lower  jaw,  must  also  inclose 
the  upper  teeth,  as  shown  in 
the  cut,  where  screws  may  be 
seen  opposite  both  lower  and 
upper  teeth. 

By  this  arrangement  the 
fragments  of  the  lower  jaw  are 
secured  not  only  relatively  to 
each  other,  but  also  to  the 
upper  jaw. 

This  splint  is  therefore 
adapted  to  the  treatment  of 
all  fractures  back  of  the  teeth, 
whether  in  the  body,  the  rami,  or  their  terminations.  In 
these  cases  the  splint  may  be  cut  away  in  front,  and 


D-- 


FIG.  2. 

B,  triangular  opening,  of  which 
one  side  corresponds  to  the  cut- 
ting edge  of  the  lateral  incisor, 
which  tooth  stood  in  the  end  of 
the  fragment  most  displaced  be- 
fore the  splint  was  applied.  C, 
opening  for  food,  speech,  &c.  D, 
channel  for  the  saliva  from  par- 
otid gland  to  enter  the  mouth, 
its  fellow  being  seen  on  the  other 
side  of  the  splint.  E,  screw  op- 
posite lower  canine  tooth,  head 
of  the  left  screw  being  just  dis- 
cernable.  E,  head  of  screw  op- 
posite upper  first  molar  tooth, 
end  of  its  fellow  being  seen  on 
the  other  side. 


7 


extended  across  the  roof  of  the  mouth,  when  there  are 
upper  and  lower  back  teeth  to  fasten  to.  and  thus  give  as 
much  room  as  possible  to  speak  and  eat  through.  Open- 
ing the  teeth  a  quajter  or  three-eights  of  an  inch  would 
not  have  any  bad  effect  on  the  position  of  the  fragments, 
even  if  the  jaw  were  broken  through  the  necks  of  both  con- 
dyles,  as  the  parts  near  the  fractures  would  move  but 
little  and  the  back  of  the  jawr  could  be  raised  high 
enough  to  keep  the  broken  surfaces  in  contact.  Even  if 
the  neck  of  one  side  only  were  broken,  the  lower  part  could 
be  kept  firmly  up  against  the  fragment  above. 

When  the  jaw  is  held  fast  to  the  upper  teeth,  especially 
when  wings  project  between  the  lips,  passages  should  be 
cut  through  the  sides  of  the  splint,  where  the  absence  of 
teeth  or  separation  of  the  jaws  gives  a  chance  for  the  saliva 
from  the  parotid  glands  to  enter  the  mouth,  otherwise  it 
may  overflow  at  the  lips. 

Fig.  3  shows  the  wings  for 
cases  having  no  teeth  in  either 
jaw — the  ends  of  the  wings 
within  the  mouth  being  im- 
bedded in  a  vulcanite  splint 
similar  in  principle  to  that  of 
Fig.  2. 

Wings  made  of  steel  or  iron 
may  be  quite  light.  They 
should  have  small  holes  every 
half  inch  to  hold  the  strings, 
lacing,  etc.  The  arch  of  the 

FI(;-3  wings  should  be  high  enough 

F,  upper  wimr.     G,  lower  wing.  A                4.1.1              i  • 

H,  mental  bancHo  hold  the  jaw  up  to  give  the  lower   lip  room  to 

in  the  splint.     I,   neck  strap    to  gO   weH    up.      The   wings    for 

keep  the  hand  hack      K,   balance  -  . 

strap  to  hold  the  cap  in  place.  each  side  of  the  jaw  are  in  one 

piece,  and  the  parts  within  the  mouth  pass  back  in  the 
line  of  the  upper  gum.  They  are  thinned  down  and  pierced 
with  holes,  that  the  rubber  in  which  they  are  imbedded  may 
hold  them  firmly. 


The  tape  strings  pass  from  the  cap  inside  and  under  the 
upper  wings,  then  up  between  them  and  the  tape  lacings, 
which  keep  the  strings  from  slipping,  to  the  cap  whence  they 
started.  The  mental  band  (which  is  only  one  thickness  of 
linen,)  passes  up  between  the  sides  of  the  lower  jaw  and  the 
wings  where  it  is  tied  by  the  strings,  which  pass  through 
the  holes.  The  band  is  cut  off  to  show  this;  but  when 
worn  it  should  be  turned  down  on  the  outside  and  pinned 
just  below  the  wings.  The  neck  strap  should  be  sewed  to 
the  mental  band  on  one  side  and  pinned  on  the  other,  and 
worn  tight  enough  to  keep  the  band  from  slipping  forward 
over  the  chin. 

The  jaw  and  splint  are  supported  by  the  cap  forward  of 
its  centre.  This  is  counterbalanced  by  the  elastic  strap 
which  passes  from  the  back  of  the  cap  down  around  an 
unelastic  and  much  heavier  strap,  extending  across  and 
fastened  to  the  shoulders  by  elastic  ends.  The  balance  strap 
returns  to  the  cap  and  is  buckled  tight  enough  to  hold  the 
jaw  up.  At  night  it  may  be  slackened  to  do  this,  with  the 
neck  flexed.  It  slides  on  the  shoulder  strap  as  the  head 
inclines  to  either  side. 

By  this  arrangement  the 
splint  is  a  resting  place  for  the 
broken  jaw,  while  the  wings 
give  firm  attachment  to  appli- 
ances which  hold  the  jaw  up 
with  the  least  possible  pressure 
upon  the  external  parts,  as  j- 
the  wings  need  not  press 
either  against  the  jaw  or  the 
zygomas. 

Fig.    4  represents    a    splin^ 

HevispH  in   186?    for  trip  II«:P  r>r     **•  wing   °f  malleable  iron,  pro- 

D3'  1(  Ejecting  with   its  fellow,   from  the 

practitioners  out  of  the   reach  splint  to  which  they  are  soldered. 

of  a   dentist,  and  for  hospital  feW^l  K» 

use.      This    splint    is    made  oflymg  il-    Lneekstrap.     The  inen- 
,  .  ,.    ,       .  .       tol  band  is  made  of   linen  or  anv 

cast  tin,  and  is  applied  with  a  thin  material. 

lining  of  gutta-percha.     It  is  in  the  shape  of  an  impression 


FIG.  4. 


cup,  and  seven  sizes  are  kept  ready  for  use  from  which  one 
can  be  selected  for  the  broken  jaw.  The  wings  are  of  mal- 
leable iron,  tinned  to  prevent  rusting  and  for  more  readily 
soldering.  Three  sizes  are  sufficient  to  select  from. 

The  splint  has  a  handle  in  front,  that  it  may  be  used  as 
a  cup  to  take  the  impression  of  the  jaw — the  holes  being 
used  to  allow  a  small  probe  to  be  pressed  through  the  wax> 
down  to  the  teeth,  thus  allowing  air  to  enter  to  facilitate  the 
removal  of  the  impression,  and  when  in  use  as  a  splint  giving 
entrance  to  warm  water  thrown  from  a  syringe,  to  keep  the 
parts  clean. 

The  splint  should  be  made  to  fit  well  by  bending,  cutting 
oft  the  edges  and  rounding  them  up  smooth.  When  a  tooth 
projects  so  as  to  keep  the  splint  from  fitting,  a  hole  may  be 
cut  to  let  the  tooth  through,  if  the  metal  cannot  be  ham- 
mered out.  This  should  all  be  done  before  taking  the 
impression,  as  a  well  fitted  cup  assists  greatly  in  this  impor- 
tant matter. 

After  the  cast  is  obtained,  the  handle  in  front  should  be 
cut  off,  and  the  wings,  if  needed,  soldered  on,  care  being 
taken  that  their  edges  are  clear  of  the  corners  of  the  mouth 
when  open.  Warm  gutta-percha  should  then  be  placed  in 
the  splint,  pressed  down  on  the  cast,  and,  alter  cooling  in 
water,  the  softened  plaster  should  be  dug  out 

This  splint  has  the  advantage  of  being  easier  of  applica- 
tion, and  can  be  applied  in  much  shorter  time  than  a  rubber 
splint,  especially  if  the  fractured  bone  can  be  set  and  held 
by  ligatures  firmly  enough  to  bear  the  pressure  of  the  warm 
gutta-percha  for  the  splint  can  thenbe  at  once  applied  to 
the  teeth,  and  the  gutta-percha  closing  around  them,  the 
bone  will  be  kept  in  place  without  other  fastenings. 

When  the  fragments  of  the  jaw  cannot  be  held  firmly 
enough  to  bear  the  pressure  of  warm  gutta-percha  without 
displacement,  Plaster  of  Paris  would  hold  the  jaw  securely 
in  the  splint  for  a  longtime.  In  these  methods  the  ligatures 
are  left  on. 


IO 

To,  D.  Hayes  Agiiitc,  Jisq.,  M.  1).,  L.  L.  I).,  Professor  of 
Surgery  in  the  ^[edieal  Department  of  the  University  of 
Pennsylvania. 

Sir : — In  the  preface  to  your  recently  completed  work 
"  The  Principles  and  Practice  of  Surgery  "  you  say  :  "  In 
the  composition  of  its  pages,  while  I  have  expressed  my 
o\vn  views  independently  on  all  subjects,  I  have  also  endeav- 
ored, as  far  as  was  consistent  with  the  scope  and  limits  of 
the  work,  to  record  those  of  other  writers,  not  only  that 
the  student  and  the  practitioner  may  be  made  familiar  with 
the  literature  of  their  profession,  but  also  that  they  may  be 
able  in  their  observation  and  practice  to  contrast  different 
plans  of  treatment,  and  in  this  way  draw  their  own  conclu- 
sions in  regard  to  the  relative  merits  of  the  various  modes 
of  managing  surgical  disease.  Whatever  may  be  the 
defects  of  the  work, — and  none  can  be  more  sensible  of 
these  than  myself, — I  have  endeavored  most  conscientiously 
to  furnish  a  safe  and  reliable  guide  for  the  surgical  practi- 
tioner." 

With  this  in  view,  those  for  whose  instruction  you  wrote 
could  not  suspect  that  the  work  contains  statements  which 
are  untrue,  and  mislead  in  regard  to  the  treatment  of  any 
important  injury.  Yet  the  section  on  "  Fracture  of  the  Infer- 
ior Maxillary  Bone  "  contains  such  statements.  To  give  a 
clear  understanding  of  the  matter  to  you,  and  to  all  who 
ma}-  read  this  letter,  I  quote  from  your  article  verbatim  and 
remark  upon  the  misrepresentations.  In  Vol.  I,  page  846 
you  refer  to  the  interdental  splints  devised  by  me  and  used 
in  treating  fractures  of  the  maxilla,  as  follows  : 

"Among  the  simplest  of  Gunning's  splints  are  the  forms 
shown  in  Figs.  642  and  643,  which  receive  all  the  teeth  of 


FIG.  642. 
Gunning's       Interdental 

Splint.     A   points  to    perfbra  FKI.  643. 

tions  for  injecting  water.  Gunning's  Interdental  Splint. 

the  lower  jaw,  extend  a  short  distance   over   the  gum,    and 


1 1 

have  perforations. through  which  to  throw  a  stream  of  liquid 
for  the  purpose  of  cleanliness.  This  splint  when  placed  in 
position  forms  a  cap,  and  is  kept  in  place  by  securing  the 
jaws  together  with  a  bandage,  or  by  means  of  scrtws  passed 
between  the  teeth." 

Now  my  splint  No.  I.  your  figure  642  was  expressly 
devised  to  be  used  without  a  bandage ;  it  holds  the  frag- 
ments of  the  jaw  in  place  by  means  of  the  teeth  without  any- 
thing external  to  the  mouth,  and  it  allows  the  jaw  to  move 
and  to  be  used  in  eating  and  speaking  ;  and  this  form  of 
splint  is  adapted  to  the  large  proportion  of  fractures 
of  the  maxilla.  If  the  patient  can  be  depended  on,  never, 
however,  if  a  child,  this  splint  may  in  many  cases  only  be 
fitted  to  the  teeth,  and  without  screws  in  or  between  the 
teeth,  or  any  ligatures,  the  fragments  of  the  jaw  will 
be  held  firmly  together. 

For  in  eating  or  in  closing  the  splint  against  the 
upper  teeth  the  muscles  carry  the  broken  jaw  up  and 
keep  the  fragments  in  place ;  the  muscles  and  the 
surrounding  soft-parts  forming  a  counter  support  to 
the  interdental  splint. 

This  splint  No.  I,  was  first  applied  on  Feb.  12,  1861.  It 
was  used  on  the  jaw  of  a  Spanish  seaman  in  the  Naval 
Hospital,  New  York,  and  it  cured  the  patient,  although 
he  had  been  subjected  to  four  months  unsuccessful  effort 
of  the  government  surgeons,  assisted  by  others  in  the 
vicinity.  Thus  the  surgeons  were  spared  the  mortifica- 
tion of  sending  the  man  home  uncured.  A  similiar  splint 
was  shown  to  the  New  York  Academy  of  Medicine,  Jan.  7, 
1863  with  another  case  in  which  it  was  used,  then  published 
with  illustrations  in  their  Bulletin ;  and  in  February 
brought  before  the  Medical  Society  of  the  State  of  New 
York,  as  shown  in  the  Transactions  for  fS6j,  and  in  the 
Medical  Report  of  the  Centennial  Commission  1876  this 
splint  was  admitted  to  be  the  first  splint  ever  used  without 
an  appliance  outside  the  mouth.  Surely  this  splint 
should  have  been  fairly  reported  and  truly  described  in 


12 


your  work  on  "The  Principles  and  Practice  of  Surgery." 
Had  this  been  done  other  sufferers  could  have  the  use  of  it ; 
whereas  your  book  misleads  the  surgeon  and  student  in  re- 
gard to  it. 

Even. in  the  few  injuries  where  the 'fractures  are  such 
that  it  is  necessary  to  use  the  upper  teeth  as  a  base  to 
hold  the  broken  lower  jaw  still;  as  in  fractures  in  the 
ascending  ramus,  or  say  all  fractures  back  of  the  teeth, 
my  splint  No.  2,  now  shown,  is  not  kept  in  .place  as  you 
say  by  securing  the  jaws  together  with  a  bandage.  This 
splint,  like  No,  I,  holds  the  fragments  of  the  jaw  by 
means  of  the  teeth  only;  without  any  bandage;  and  while 
the  patient  wears  this  splint  they  may  follow  as  with  No.  I , 
their  usual  occupations.  Of  my  splint  No.  3  you  say  : 
GUNNING'S  INTERDENTAL  SPLINT. 

"A  third  splint  of  Dr.  Gun- 
ning's; one  which  he  uses  in 
cases  where  the  teeth  have 
been  lost  is  formed  by  connect- 
ing steel  branches  with  the 
interdental  part  of  the  appa- 
ratus, of  which  the  upper 
branch  passes  along  the  su- 
perior part  of  the  face,  and  the 
lower  one  along  the  outside 
of  the  lower  jaw ;  these  are 

kept  in  place   by  three  bands, 
FIG.  644. 

one  being  placed  at  the  chin  in  order  to  hold  the  jaw  up  in 
the  splint,  one  running  from  the  metal  band  to  the  back 
of  tlie  neck,  and  one  passing  to  a  cap  which  is  worn  over 
the  head,  and  with  which  the  splint  is  connected." 

This  is  my  plate  3  with  its  reference  letters  cut  away  and 
your  description  leads  the  reader  to  suppose  that  a  band 
of  metal  goes  under  the  chin  to  hold  the  jaw  up  in  the 
splint ,  and  that  metal  bands  are  used  instead  of  strings  of 
tape  to  hold  the  splint  by  means  of  the  cap  and  to  keep 


13 

a  7;/dWz/band  from  slipping  over  the  chin.  But  no  mc'ta/band 
is  used  any  where  nor  spoken  of  by  me.  In  the  absence 
of  teeth  the  wings  are  used,  two  on  each  side,  the  upper 
range  over  the  malar  bones  and  the  lower  along  the  jaw; 
and  from  the  cap  on  the  head  tape  strings  pass  down  on 
each  side  to  the  upper  wings  and  hold  the  splint  against 
the  upper  gum,  while  the  broken  lower  jaw  is  held  up  in 
the  splint  by  a  single  thickness  of  linen  or  other  thin 
material  which  extends  across  under  the  chin  from  one 
lower  wing  to  the  other;  while  the  lips,  cheeks  and  all  the 
face  are  left  free  from  presure. 

This  statement  would  place  the  splint  plainly  before  your 
readers,  and  give  them  the  use  of  it,  for  their  patients, 
when  they  needed  or  preferred  it.  This  description  is  also 
briefer  than  your  deceptive  text.  Certainly  this  splint  No. 
3.  (your  figure  644,)  deserves  fair  notice,  it  having  been  suc- 
cessfully used  on  the  bad  fractures  of  the  Hon.  William  H. 
.Seward  subsequent  to  the  attempt  to  assassinate  him. 

Surgeon  General  Barnes  and  Surgeon  Basil  Norris  of 
the  army,  together  with  Dr.  VVhelan,  chief  of  the  Medical 
Bureau  of  the  Navy,  and  others  had  signally  failed  to 
secure  by  ligatures  and  bandages  the  fractures  received  in 
falling  •  from  his  carriage,  before  the  Secretary  was  cut 
so  terribly  on  the  night  that  President  Lincoln  was  killed. 

Further  I  did  not  take  charge  of  the  case  nor  set  the 
fractures  until  twenty  five  (25)  days  after  the -accident, 
fifteen  after  the  attempt  to  kill  him,  yet  this  splint  with  up- 
per wings  held  the  double  and  compound  fractures  of  the 
jaw  securely  for  sixty-eight  days  without  a  moment's  inter- 
mission. 

I  described  this  splint  No.  3,  to  the  New  York  Academy 
of  Medicine,  June  I.  1864,  but  the  upper  wings  were  never 
used  until  I  applied  them  May  2,  1865,  in  Mr  Seward's 
case. 

Since  then  a  severe  fracture  without  a  tooth  in  the 
mouth  has  been  treated  successfully;  in  which  both  upper 
and  also  the  lower  wings  were  used.  It  was  applied  in 


May  1879,  to  the  jaw  of  a  farmer  70  years  old  with  such 
good  results,  by  Dr.  J.  Adams  Bishop ;  reported  in 
Johnston's  Dental  Miscellany  Vol.  VII,  p.  63  and  in  the 
Independent  Practitioner  Vol.  II,  p.  108.  Thus  the  splint 
Xo.  3  has  been  fully  tested,  for  this  patient's  fracture 
could  not  be  held  by  the  bandages  used  by  the  Physicians 
who  first  attended  the  case.  I  devised  this  splint  for 
fractures  without  teeth  to  hold  by,  and  it  has  proved 
to  be  a  perfect  control  for  such  cases  ;  for  the  Secretary  of 
State  attended  to  the  duties  of  his  office  while  wearing 
it,  and  the  farmer  walked  around  at  once;  and  followed 
his  plough  and  did  heavy  work  before  his  splint  was  left  off, 
although  he  wore  it  only  six  weeks. 

The  deception  of  your  text  in  regard  to  my  treatment  of 
these  injuries  is  made  complete  by  leaving  out  my  splint 
No.  4  here  shown. 

This  splint  made  of  tin  and 
applied  to  the  teeth  of  the 
fractured  jaw  by  means  of  a 
lining  of  gutta  percha,  or  of 
Plaster  of  Paris,  was  devised 
in  1863,  for  hospital  use  and 
for  practitioners  out  of  the 
reach  of  a  dentist.  It  is  cast 
--H  with  a  handle  in  front,  so  that 
it  is  an  impression  cup  such  as 
FIG.  4.  dentists  use,  but  when  applied 

as  a  splint,  the  handle  is  cut  off,  and,  if  needed,  wings  are 
soldered  on,  and  from  these  when  the  splint  is  worn  a 
single  thickness  of  roller  passes  under  the  jaw  from  one 
wing  to  the  other. 

I  reported  this  splint  to  the  New  York  Academy  of 
Medicine  June  I,  1864,  in  answer  to  their  request  and  let- 
ter of  thanks  in  1863.  Within  the  week  after  reading  the 
paper  I  applied  this  splint  No.  4  to  the  jaw  of  a  boy  under 
Dr.  Freeman's  treatment  and  in  July  1  used  the  same  splint 
with  a  new  lining,  on  the  jaw  of  a  boy  sent  to  me  by 


15 

Dr.   King.     The  indentations  shown  in  the  cut  represent 
those  made  by  the  upper  teeth  of  both  boys  when  eating. 

The  splints  Nos.  1,2,  3,  and  4,  with  cases  to  explain  and 
illustrate  the  treatment  are  clearly  shown  in  my  paper  on 
the  "  Treatment  of  Fractures  of  the  Lower  Jaw  by  Inter- 
dental Splints;  "  first  published  in  1866;  they  are  also  dis- 
tinctly and  fairly  shown  in  every  edition  of  that  unique 
work  "  INJURIES  AND  DISEASES  OF  THE  JAWS,"  BY  CHRISTO- 
PHER HEATH,  F.  R.  C.  S.  published  by  John  Churchill  &  Son, 
London,  and  by  Lindsay  &  Blackiston,  Philadelphia,  (this 
work  is  the  Jacksonian  Prize  Essay  of  the  Royal  College  of 
Surgeons  of  England,  for  1867.) 

The  splints  are  also  described  at  length  and  favorably 
noticed  in  the  Report  of  the  Judges  of  Group  XXIV  on 
Medicine,  Surgery  and  Prothesis,  transmitted  by  the  Secre- 
tary, J.  H.  Thompson,  A.  M..  M.  D.  to  Prof.  Francis  A. 
Walker,  Chief  of  the  Bureau  of  Awards  and  edited  by  him 
for  the  U.  S.  Centennial  Commission,  and  issued  by  your 
own  Publishers,  J.  B.  Lippincott  &  Co.,  Phil.,  before  your 
work,  "The  Principles  and  Practice  of  Surgery."  In  all 
these  publications  the  splints  are  explained  and  illustrated 
by  the  same  plates  used  in  your  articles  upon  "Fractures 
of  the  lower  Maxilla."  But  your  book  shows  my  plates 
with  the  reference  letters  cut  away,  except  to  the  holes  for 
syringing,  and  states  that  the  splints  are  held  in  place  by 
securing  the'jaws  together  with  a  bandage.  Whereas  my 
interdental  splints  were  expressly  devised  to  obviate  the 
use  of  these  bandages  which  are  cumbersome,  unreliable 
and  often  destructive.  These  splints  are  not  as  you 
intimate  merely  supplemental;  each  one  is  a  complete  and 
reliable  support.  The  first  is  for  all  injuries  in  which  the 
fractured  jaw  is  allowed  in  my  methods  to  move  naturally 
while  under  treatment  and  by  far  the  larger  proportion  of 
fractures  can  be  thus  treated. 

The  second  splint. is  for  fractures  in  which  the  broken  jaw 
is  held  in  fixed  relation  to  the  upper  one  ;  and  in  some  of 
these  cases  this  splint  does  not  cover  the  front  teeth;  so 
that  when  worn  it  is  unseen. 


i6 

All  the  splints  have  small  openings  to  allow  observation 
of  the  teeth  which  are  near  the  fractures  so  that  the  position 
of  the  broken  ends  of  the  bone  can  be  learned  at  any  time 
without  removing  the  splint;  and  in  fractures  in  which  the 
lower  jaw  is  held  in  fixed  relation  to  the  upper  one,  the 
splint  has  channels  for  the  saliva  from  the  parotid  glands  to 
pass  in  around  the  tongue. 

You  leave  these  important  devices  unnoticed  and  cut 
away  the  letters  of  reference,  yet  in  the  text  given  (say  7 
lines )  to  my  splints  I  and  2,  you  t\vice  remark  upon  keep- 
ing the  splint  clean,  and  twice  say  or  suggest  that  they 
cover  all  the  teeth  of  the  lower  jaw;  and  then  leave  your 
readers  ignorant  and  misled  in  respect  to  the  radical 
features  of  the  splints.  But  in  less  than  the  room  given  to 
the  repetition  you  could  have  told  that  these  splints  hold 
the  fragments  of  the  bone  in  -place  securely  without  any 
thing  outside  the  mouth,  are  quite  comfortable,  and  the 
patients  attend  to  their  business  and  move  about  as 
when  their  jaws  are  sound.  They  do  this  even  when 
the  fractures  are  so  severe  that  the  jaw  is  held  in 
fixed  relation  to  the  upper  teeth,  for  in  such  cases  the 
opening  in  front  affords  room  through  which  to  speak  and 
receive  food.  But  in  most  fractures  as  before  stated,  the 
jaw  is  allowed  to  move;  and  the  top  of  the  splint  is  used  in 
eating. 

The  8  cases  in  my  paper  which  show  the  complete 
control  attained  by  means  of  these  splints  were  carefully 
selected,  and  with  the  4  cuts  spoken  of  in  this  letter,  place 
my  treatment,  shown  fully  in  1866  at  the  service  of  all. 
Mr.  Christopher  Heath  quotes  from  the  New  York  Medical 
Journal and  the  British  Journal  of  Dental  Science  1 866,  and 
his  book  shows  my  treatment  clearly.  In  its  appendix 
Case  VI  is  my  report  verbatim  of  the  Hon.  Wm.  H. 
Seward's  case. 

The  Official  Report  of  the  United  State  Centennial 
Commission  closes  in  respect  to  my  treatment  of  fractures 
of  the  maxilla  as  follows  : 


17 

"In  connection  with  the  splints  shown,  was  a  series  of 
casts  illustrating  the  double  compound  fracture  of  the 
jaw  of  the  late  Hon.  Wm.  H.  Seward,  showing  the  jaw 
broken  on  both  sides  between  the  bicuspid  teeth.  Also  a 
double  cast  of  the  upper  and  lower  jaw  as  held  by  the  splint 
for  sixty-eight  days.  As  no  teeth  were  left  in  the  upper  jaw, 
the  wings  and  cap  were  used  as  shown  in  Fig.  3.  The  re- 
sult was  thoroughly  satisfactory." 

The  Secretary  Dr.  J.  Henry  Thompson  who  transmitted 
this  report  of  the  Judge  of  Group  XXIV  was  a  resident 
of  Washington,  D.  C.  where  I  treated  the  Secretary  of  State. 
In  addition  to  all  this  your  own  City,  Philadelphia,  has 
in  one  of  its  prominent  men  a  proof  of  the  superiority  of 
my  treatment  by  splint  over  that  by  bandage  as 
used  by  Professor  Buckingham  of  the  Medical  School 
of  Harvard  University.  The  fracture  was  received  in 
the  terrible  stage  accident  in  the  White  Mountains  in 
1873,  and  the  jaw  when  the  patient  was  brought  to  me,  was 
so  deformed  that  I  had  to  break  it  apart.  The  splint  was 
shown  in  the  Centennial  Exhibition  of  1876  and  the  case  is 
fully  reported  in  the  Independent  Practitioner t  Vol.  i,  p.  526. 
I  have  said  that  you  leave  out  my  splint  4 ;  but  worse 
still  you  place  next  after  my  Fig.  3  a  splint  which  you  show 
as  Kingsley's  preceded  by  a  description  which  ends  as  fol- 
lows :  "  When  applied,  the  teeth  occupy  the  cavities  in  the 
splint,  the  latter  being  kept  in  position  by  a  strip  of  roller 
passing  beneath  the  chin  from  one  arm  of  the  apparatus  to. 
the  other." 

Now  this  method,   the  splint  and   the  wings  (arms)  were 
devised  by  me. 

The  splint  with  its  wings    was  shown  on    the  patient   to 
the  New  York    Academy  of  Medicine,  October  2ist,  1863. 
It  was  for  showing  this  apparatus  that  the  Academy  passed 
the    resolution  thanking   me  and    requesting  me  to  report 
further;  and    in  response  to    which  I  read  the    paper,  June 
1st,  1864,  which  explained    my  four  splints.     (See  Bulletin 
Vol.  2,  pp.  153,  168  and  307. 
2 


i8 

Kingsley  does  not  use  the  splint  nor  the  roller  as  you 
say,  but  applies  a  sub-mental  splint  or  compress  which  is 
by  means  of  some  apparatus  or  band  kept  in  connection 
with  the  interdental  splint,  the  broken  jaw  being  between 
them,  and  he  maintains  that  this  is  necessary.  But  for  frac- 
ture at  the  angle  of  the  jaw  or  in  the  parts  above,  he  says 
that  an  interdental  splint  is  useless  and  that  a  bandage  is 
indicated,  that  is  a  bandage  around  the  jaw  and  head.  Thus 
Kingsley  uses  appliances  external  to  the  mouth  in  all  cases 
although  my  interdental  splint,  which  by  enclosing  all  the 
lower  back  teeth,  holds  in  the  angles  of  the  jaw,  has  been 
in  use  since  February  12,  1864,  his  treatment  of  "  Fracture 
of  the  Jaw  "  is  no  improvement  upon  that  of  twenty-five 
years  ago.  In  fact  he  advises  for  fracture  in  front  of  the 
jaw,  that  which  is  inferior  to  Hayward's  plan  of  1858,  in 
which  a  metal  cap  was  fitted  to  several  teeth  on  each  side  of 
the  fracture  and  from  the  upper  surface  of  the  cap  a  stout 
wire  went  out  of  each  corner  of  the  mouth  to  a  gutta-percha 
splint  under  the  chin,  and  from  beneath  this  a  four-tailed 
bandage  passed  behind  and  over  the  head, thus  the  lowertails 
passed  outside  the  angles  which  could  therefore  be  held  in 
with  pads.  Whereas,  Kingsley  says  :  "  If  the  fracture  is 
in  front,  the  splint  need  not  cover  all  the  back  teeth  ;  but  if 
it  be  at  the  side,  it  is  better  to  cover  all  the  teeth  of  that 
side.  It  is  also  better  to  set  the  ends  of  the  upper  and  lower 
jaws  in  an  articulator,  and  thus  make  prints  of  the  upper 
teeth  in  the  wax,  to  be  retained  in  the  "  splint."  But  with 
the  splint  cut  off  so  as  not  to  enclose  the  back  teeth,  the 
angles  will  be  forced  out  by  the  muscular  traction  on  the 
inside  of  the  chin,  for  the  outside  wings  can  not  be  used 
beyond  the  ends  of  the  splint  as  they  would  lift  it  up  from 
the  front  teeth.  In  fact  the  muscular  traction  on  the  inside 
of  the  chin  might  alone  wring  the  fractured  ends  out  of  the 
splint  by  forcing  the  latter  up  the  outer  surfaces  of  the 
canine  or  bicuspid  teeth. 

Again  if  the  splint  only  covered  the  teeth  on  the  fractured 
side,  then  those  of  the  other  would  have  no  bearing  and  no 


'9 

eating  could  be  done  except  on  the  splint  over  the  fracture, 
and  if  the  patient  should  happen  to  use  the  uncovered  teeth 
on  a  large  morsel  it  might  force  the  fractured  ends  apart 
whether  they  were  in  the  side  or  in  the  front  of  the  jaw. 
Dr.  Kingsley's  examples  of  the  application  of  this  splint  to 
double  or  triple  fractures  are  quite  as  bad  as  his  advice  in 
regard  to  single  fractures.  All  he  shows  of  importance  was 
first  devised,  used  and  published  by  others  before  him  ;  it 
is  as  told  by  him  of  little  service  to  the  reader  because  of 
its  intermixture  with  statements  which  are  not  in  accord 
with  the  facts  of  history  nor  of  science. 

Yet  your  text  is  such  as  leads  the  reader  to  adopt  his 
treatment  and  reject  my  methods  this  not  because  of  any 
want  of  clearness  in  my  description  for  you  could  have 
quoted  from  my  paper  in  the  Neiv  York  Medical  Journal, 
Vol.  3,  p.  434,  "  When  a  well  adapted  splint  is  on  the  teeth 
and  gum,  the  other  parts  around  the  bone  are,  to  a  great 
extent  a  counter-support  to  the  splint  Mean- 

while the  motions  of  the  jaw  are  in  most  cases  unrestricted, 
and  the  cheeks  and  lips  always  left  free."  I  bid  442  "  Fig. 
i  is  the  representative  splint  for  treatment  of  cases  in  the 
first-class  or  those  in  which  the  jaw  is  left  free.  Fig.  2  for 
the  second  class,  or  those  in  which  the  jaw  is  held  still." 

Yet  with  this  plainly  stated  you  class  these  splints  together 
and  say,  "  This  splint  when  placed  in  position,  forms  a  cap^ 
and  is  kept  in  place  by  securing  the  jaws  together  with  a 
bandage,  or  by  means  of  screws  passed  between  the  teeth." 
Your  text  on  page  847  confirms  this  as  follows  :  "  The  splint 
of  Dr.  Bean  resembles  closely  that  of  '  Dr.  Gunning  ' 

*  *  '  The  splint  when  applied  is  kept  in  position  by 
straps  which  pass  over  and  around  the  head,  and  also 
behind  the  neck.'  Your  text  again  misleads  the  student, 
for  you  admit  that  Beans'  Splint  '  is  fitted  to  the  teeth  of 
both  the  upper  and  lower  maxilla,'  in  which  cases  my  splint 
is  screwed  to  the  teeth  and  while  I  use  nothing  outside,  the 
mouth,  you  lead  the  reader  to  suppose  that  I  use  a  bandage 
around  the  jaw  and  head  and  you  do  this  although  my 


2O 

treatment  of  fracture,  with  the  splint  illustrated  by  Fig.  2r 
(your  Fig,  643)  is  related  in  the  Ntw  York  Medical  Journal, 
Vol.  4,  p.  1 6.  In  case  5  it  is  distinctly  shown  that  the 
surgeon  in  Bellevue  Hospital  who  had  charge  of  the  woman 
tried  to  hold  the  jaw  up  in  the  splint  with  Hamilton's  ban- 
dage but  on  the  third  day  he  requested  me  to  screw  the 
splint  fast  to  the  teeth,  as  the  bandage  was  painful  and  use- 
less. The  splint  was  screwed  to  the  teeth  and  the  jaw  united 
in  forty  days. 

In  January,  1861,   Dr.  Benjamin  Franklin  Bache,  United 
States  Navy,  advised  that  I  should  be  asked  to  treat  a  Span- 
ish seaman,  whose  fractured  jaw  was  found    to  be  incurable 
at   the    Naval  Hospital,    New   York.     Howard  Hayward's 
method  of  treating  these  inj  uries  was  then  the  most  advanced 
and  although  it  was  very  imperfect  did  much  to  prepare  the 
minds  of  surgeons  to  accept  the  co-operation  of  dentists,  at 
least  in  Great  Britian.     After  study  of  the  literature  of  the 
subject   say   as  given    for  twenty-three   centuries  back  and 
then    making   careful    allowance    for  the    muscular   action 
involved,  I    devised  the    splints  and    methods  of  applying 
them,    which    were  fully  published  ;  and  the  correct  action 
of  the  muscles   which    control  the  jaw  was  shown  to  guide 
the  surgeon.     This    was  necessary  as    I  demonstrated    that 
the  external ptery gold  muscles  depressed  the  jaw  and  opened 
the  mouth,  instead  of  the  digastrics  as  maintained  by  Hun- 
ter.    I  also    explained    that  the  lower  jaw  is  the    lever  by 
which    the    head  is  held    forward    so  that  when    the  jaw  is 
broken,    it    requires  firmer   control    than  can    be  given    by 
appliances  which    rest  upon  the   soft  parts    external  to  the 
mouth.     In  the  years  which  have  since  passed,    my  exper- 
ience has  suggested  nothing  which  I  think  necessary  to  per- 
fect my  treatment  of  fractures  of  the  maxillae. 

You  however  do  not  show  my  splints  and  methods fairfy 
in  order  that  your  readers  may  contrast  my  plans  with 
others  and  judge  of  their  relative  merits  as  the  student  is 
led  to  believe  by  your  preface. 

I  trust  that  you  have  been  yourself  imposed  upon,  and 
that  you  will  now  and  in  the  future  as  far  as  possible  correct 


21 


the  wron^  which  has  at  present  the  sanction  of  your  name. 
I  am,  Sir, 

Yours  Respectfully, 

THOMAS  BRIAN  GUNXINC,. 


(Copy.) 

PHILADELPHIA, 

l6ll    CHESTNUT  STREET, 

December  ist,  1883. 
DR.  THOMAS  BRIAN  (irxM.v;, 
Dear  Doctor  : — 

I  am  indebted  to  you  for  an  accurate  description  of  your 
interdental  splints  for  fracture  of  the  jaw,  and  shall  with 
^reat  pleasure  make  the  correction  in  the  next  edition  of  my 
book  should  it  reach  a  second  edition. 

Very  Truly  Yours,  &c., 

D.  HAYES  AGNEW. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


Form  L9-116m-8,'62(D1237s8)444 


I 


